Form: Formative Assessment of Clinical Competencies Checklist for Interns(Effective FA12)

Owner: COMD Program Account <VSUCOMD>
Owner's Email: lawagner@valdosta.edu
Dataset: Formative Assessment of Clinical Competencies for Interns
EDIT: Y, VIEW: N, REQR: N
1
Student Name
Please enter First Name then Last Name
EDIT: Y, VIEW: N, REQR: N
2
Clinical Level
I
II
III
IV
V
EDIT: Y, VIEW: N, REQR: N
3
Semester/Year
Fall 2005
Spring 2006
Summer 2006
Fall 2006
Spring 2007
Summer 2007
Fall 2007
Spring 2008
Summer 2008
Fall 2008
Spring 2009
Summer 2009
Fall 2009
Spring 2010
Summer 2010
Fall 2010
Spring 2011
Summer 2011
Fall 2011
Spring 2012
Summer 2012
Fall 2012
Spring 2013
Summer 2013
Fall 2013
Spring 2014
Summer 2014
Fall 2014
Spring 2015
Summer 2015
Fall 2015
Spring 2016
Summer 2016
EDIT: Y, VIEW: N, REQR: N
4
Check all categories in which the student performed evaluations.
Hearing
Articulation
Receptive/Expressive Language
Fluency (F)
Voice & Resonance
Social Aspects of Communication
Cognitive Aspects of Communication
Swallowing
EDIT: Y, VIEW: N, REQR: N
5
Conduct screening and implement prevention information and procedures.
4 = Independence: Self-directed, Demonstrates Competency; 3 = Minimal Assistance: Occasional Assistance, Minimal Direction to Demonstrate Competency, 25% or less guidance to Complete Tasks; 2 = Moderate Assistance: Frequent Assistance, Moderate Direction to Demonstrate Competency, Aware With Cues, 40-50% Guidance; 1 = Maximum Assistance: Near Total Dependence, Unable to Demonstrate Competency on Consistent Basis, 75-90% Guidance
4
3
2
1
Not able to rate
EDIT: Y, VIEW: N, REQR: N
6
Collect and integrate case history information from clients, parents, teachers and other professionals.
4 = Independence: Self-directed, Demonstrates Competency; 3 = Minimal Assistance: Occasional Assistance, Minimal Direction to Demonstrate Competency, 25% or less guidance to Complete Tasks; 2 = Moderate Assistance: Frequent Assistance, Moderate Direction to Demonstrate Competency, Aware With Cues, 40-50% Guidance; 1 = Maximum Assistance: Near Total Dependence, Unable to Demonstrate Competency on Consistent Basis, 75-90% Guidance
4
3
2
1
Not able to rate
EDIT: Y, VIEW: N, REQR: N
7
Select and administer appropriate evaluation procedures, such as behavioral observations, non-standardized, standardized tests, and instrumental procedures.
4 = Independence: Self-directed, Demonstrates Competency; 3 = Minimal Assistance: Occasional Assistance, Minimal Direction to Demonstrate Competency, 25% or less guidance to Complete Tasks; 2 = Moderate Assistance: Frequent Assistance, Moderate Direction to Demonstrate Competency, Aware With Cues, 40-50% Guidance; 1 = Maximum Assistance: Near Total Dependence, Unable to Demonstrate Competency on Consistent Basis, 75-90% Guidance
4
3
2
1
Not able to rate
EDIT: Y, VIEW: N, REQR: N
8
Adapt evaluation procedures to meet client needs.
4 = Independence: Self-directed, Demonstrates Competency; 3 = Minimal Assistance: Occasional Assistance, Minimal Direction to Demonstrate Competency, 25% or less guidance to Complete Tasks; 2 = Moderate Assistance: Frequent Assistance, Moderate Direction to Demonstrate Competency, Aware With Cues, 40-50% Guidance; 1 = Maximum Assistance: Near Total Dependence, Unable to Demonstrate Competency on Consistent Basis, 75-90% Guidance
4
3
2
1
Not able to rate
EDIT: Y, VIEW: N, REQR: N
9
Interpret, integrate, and synthesize all information to develop diagnoses and make recommendations for intervention.
4 = Independence: Self-directed, Demonstrates Competency; 3 = Minimal Assistance: Occasional Assistance, Minimal Direction to Demonstrate Competency, 25% or less guidance to Complete Tasks; 2 = Moderate Assistance: Frequent Assistance, Moderate Direction to Demonstrate Competency, Aware With Cues, 40-50% Guidance; 1 = Maximum Assistance: Near Total Dependence, Unable to Demonstrate Competency on Consistent Basis, 75-90% Guidance
4
3
2
1
Not able to rate
EDIT: Y, VIEW: N, REQR: N
10
Complete administrative and reporting functions necessary to support evaluation.
4 = Independence: Self-directed, Demonstrates Competency; 3 = Minimal Assistance: Occasional Assistance, Minimal Direction to Demonstrate Competency, 25% or less guidance to Complete Tasks; 2 = Moderate Assistance: Frequent Assistance, Moderate Direction to Demonstrate Competency, Aware With Cues, 40-50% Guidance; 1 = Maximum Assistance: Near Total Dependence, Unable to Demonstrate Competency on Consistent Basis, 75-90% Guidance
4
3
2
1
Not able to rate
EDIT: Y, VIEW: N, REQR: N
11
Refer clients for appropriate services.
4 = Independence: Self-directed, Demonstrates Competency; 3 = Minimal Assistance: Occasional Assistance, Minimal Direction to Demonstrate Competency, 25% or less guidance to Complete Tasks; 2 = Moderate Assistance: Frequent Assistance, Moderate Direction to Demonstrate Competency, Aware With Cues, 40-50% Guidance; 1 = Maximum Assistance: Near Total Dependence, Unable to Demonstrate Competency on Consistent Basis, 75-90% Guidance
4
3
2
1
Not able to rate
EDIT: Y, VIEW: N, REQR: N
12
Check all available documentation of student's abilities in the area of evaluation: clinic prevention materials, referrals made, dx planning sessions, coursework, seminars, IEP's, staffings, clinical reports, supervisory feedback, portfolio, grade forms, clock hour forms, other
clinic prevention materials
referrals made
dx planning sessions
coursework
seminars
IEP's
staffings
clinical reports
supervisory feedback
portfolio
grade forms
clock hour forms
other
EDIT: Y, VIEW: N, REQR: N
13
Check all categories in which the student conducted intervention.
Hearing
Articulation
Receptive/Expressive Language
Fluency (F)
Voice & Resonance
Social Aspects of Communication
Cognitive Aspects of Communication
Swallowing
EDIT: Y, VIEW: N, REQR: N
14
INTERVENTION: Develop appropriate intervention plans with measurable and achievable goals that meet client needs. Collaborate with clients and relevant others in the planning process.
4 = Independence: Self-directed, Demonstrates Competency; 3 = Minimal Assistance: Occasional Assistance, Minimal Direction to Demonstrate Competency, 25% or less guidance to Complete Tasks; 2 = Moderate Assistance: Frequent Assistance, Moderate Direction to Demonstrate Competency, Aware With Cues, 40-50% Guidance; 1 = Maximum Assistance: Near Total Dependence, Unable to Demonstrate Competency on Consistent Basis, 75-90% Guidance
4
3
2
1
Not able to rate
EDIT: Y, VIEW: N, REQR: N
15
INTERVENTION: Implement intervention plans (involve clients and relevant others in the intervention process).
4 = Independence: Self-directed, Demonstrates Competency; 3 = Minimal Assistance: Occasional Assistance, Minimal Direction to Demonstrate Competency, 25% or less guidance to Complete Tasks; 2 = Moderate Assistance: Frequent Assistance, Moderate Direction to Demonstrate Competency, Aware With Cues, 40-50% Guidance; 1 = Maximum Assistance: Near Total Dependence, Unable to Demonstrate Competency on Consistent Basis, 75-90% Guidance
4
3
2
1
Not able to rate
EDIT: Y, VIEW: N, REQR: N
16
INTERVENTION: Select or develop and use appropriate materials and instrumentation for prevention and intervention.
4 = Independence: Self-directed, Demonstrates Competency; 3 = Minimal Assistance: Occasional Assistance, Minimal Direction to Demonstrate Competency, 25% or less guidance to Complete Tasks; 2 = Moderate Assistance: Frequent Assistance, Moderate Direction to Demonstrate Competency, Aware With Cues, 40-50% Guidance; 1 = Maximum Assistance: Near Total Dependence, Unable to Demonstrate Competency on Consistent Basis, 75-90% Guidance
4
3
2
1
Not able to rate
EDIT: Y, VIEW: N, REQR: N
17
INTERVENTION: Measure and evaluate client performance progress.
4 = Independence: Self-directed, Demonstrates Competency; 3 = Minimal Assistance: Occasional Assistance, Minimal Direction to Demonstrate Competency, 25% or less guidance to Complete Tasks; 2 = Moderate Assistance: Frequent Assistance, Moderate Direction to Demonstrate Competency, Aware With Cues, 40-50% Guidance; 1 = Maximum Assistance: Near Total Dependence, Unable to Demonstrate Competency on Consistent Basis, 75-90% Guidance
4
3
2
1
Not able to rate
EDIT: Y, VIEW: N, REQR: N
18
INTERVENTION: Modify intervention plans, strategies, materials, or instrumentation as appropriate to meet client needs.
4 = Independence: Self-directed, Demonstrates Competency; 3 = Minimal Assistance: Occasional Assistance, Minimal Direction to Demonstrate Competency, 25% or less guidance to Complete Tasks; 2 = Moderate Assistance: Frequent Assistance, Moderate Direction to Demonstrate Competency, Aware With Cues, 40-50% Guidance; 1 = Maximum Assistance: Near Total Dependence, Unable to Demonstrate Competency on Consistent Basis, 75-90% Guidance
4
3
2
1
Not able to rate
EDIT: Y, VIEW: N, REQR: N
19
INTERVENTION: Complete administrative and reporting functions necessary to support intervention.
4 = Independence: Self-directed, Demonstrates Competency; 3 = Minimal Assistance: Occasional Assistance, Minimal Direction to Demonstrate Competency, 25% or less guidance to Complete Tasks; 2 = Moderate Assistance: Frequent Assistance, Moderate Direction to Demonstrate Competency, Aware With Cues, 40-50% Guidance; 1 = Maximum Assistance: Near Total Dependence, Unable to Demonstrate Competency on Consistent Basis, 75-90% Guidance
4
3
2
1
Not able to rate
EDIT: Y, VIEW: N, REQR: N
20
INTERVENTION: Refer clients for services as appropriate.
4 = Independence: Self-directed, Demonstrates Competency; 3 = Minimal Assistance: Occasional Assistance, Minimal Direction to Demonstrate Competency, 25% or less guidance to Complete Tasks; 2 = Moderate Assistance: Frequent Assistance, Moderate Direction to Demonstrate Competency, Aware With Cues, 40-50% Guidance; 1 = Maximum Assistance: Near Total Dependence, Unable to Demonstrate Competency on Consistent Basis, 75-90% Guidance
4
3
2
1
Not able to rate
EDIT: Y, VIEW: N, REQR: N
21
Communicate effectively, recognizing the needs, values, preferred mode of communication, an dcultural/ linguistic background of clients, family, caregivers and relevant others.
4 = Independence: Self-directed, Demonstrates Competency; 3 = Minimal Assistance: Occasional Assistance, Minimal Direction to Demonstrate Competency, 25% or less guidance to Complete Tasks; 2 = Moderate Assistance: Frequent Assistance, Moderate Direction to Demonstrate Competency, Aware With Cues, 40-50% Guidance; 1 = Maximum Assistance: Near Total Dependence, Unable to Demonstrate Competency on Consistent Basis, 75-90% Guidance
4
3
2
1
Not able to rate
EDIT: Y, VIEW: N, REQR: N
22
Collaborate with other professionals in case management.
4 = Independence: Self-directed, Demonstrates Competency; 3 = Minimal Assistance: Occasional Assistance, Minimal Direction to Demonstrate Competency, 25% or less guidance to Complete Tasks; 2 = Moderate Assistance: Frequent Assistance, Moderate Direction to Demonstrate Competency, Aware With Cues, 40-50% Guidance; 1 = Maximum Assistance: Near Total Dependence, Unable to Demonstrate Competency on Consistent Basis, 75-90% Guidance
4
3
2
1
Not able to rate
EDIT: Y, VIEW: N, REQR: N
23
Provide counseling regarding communication and swallowing disorders to clients, family, caregivers and relevant others.
4 = Independence: Self-directed, Demonstrates Competency; 3 = Minimal Assistance: Occasional Assistance, Minimal Direction to Demonstrate Competency, 25% or less guidance to Complete Tasks; 2 = Moderate Assistance: Frequent Assistance, Moderate Direction to Demonstrate Competency, Aware With Cues, 40-50% Guidance; 1 = Maximum Assistance: Near Total Dependence, Unable to Demonstrate Competency on Consistent Basis, 75-90% Guidance
4
3
2
1
Not able to rate
EDIT: Y, VIEW: N, REQR: N
24
Adhere to the ASHA Code of Ethics and behave professionally.
4 = Independence: Self-directed, Demonstrates Competency; 3 = Minimal Assistance: Occasional Assistance, Minimal Direction to Demonstrate Competency, 25% or less guidance to Complete Tasks; 2 = Moderate Assistance: Frequent Assistance, Moderate Direction to Demonstrate Competency, Aware With Cues, 40-50% Guidance; 1 = Maximum Assistance: Near Total Dependence, Unable to Demonstrate Competency on Consistent Basis, 75-90% Guidance
4
3
2
1
Not able to rate
EDIT: Y, VIEW: N, REQR: N
25
Check all available documentation of student's abilities in the area of intervention:
lesson plans
protocol sheets
IEPs
staffings
supervisory feedback
SOAP notes
data sheets
progress reports
grade forms
clock hour forms
portfolio
coursework
seminars
other